Name *

First Name

Last Name

Phone Number *

(###)

###

####

Date of birth

MM

DD

YYYY

Do you have, or have you ever experienced, any of the following?

Please check all that apply.

Circulatory disorder

Respiratory disorder

Heart condition

High/low blood pressure

Thrombosis

Dizzyness

Blackouts

Dental complaints

Varicose veins

Epilepsy

Diabetes

Skin disorder

Bowel complaint

Bladder complaint

Visual disturbances

Allergies

Arthritis

Osteoperosis/osteopenia

Nervous system disorder (MS, stroke)

Headaches

Ringing in the ears

Eating disorders

Consent for treatment and physical examination

Thank you for providing us with the relevant information on your medical status and your personal details. An MFR treatment consists of a discussion concerning general medical information and specific information regarding your present complaint after which a physical examination will be carried out. This will include an in-depth assessment of your presenting complaint as well as any other relevant examination procedures. In subsequent visits, further assessments will be carried out to establish changes to your posture and function and presenting complaint. I understand that my treatment is non-sexual, charges will apply if I give less than 24 hours notice of any cancellation, and that I must inform my therapist if my medical circumstances change at any time.

I understand and consent.